Haematology

Question 1

How is VWF inherited? What are the levels of platelets, bleeding time, PT and APTT

Answer 1

Autosomal Dominant

Normal platelets (number not affected)
Prolonged bleeding time
Normal PT but prolonged APTT

Nb// Reduced Factor 8 level slightly (but not as much as Haemophilia A)

Question 2

What do you do if patient is on warfarin and there is bleeding, with INR >5

Answer 2

stop warfarin. IV Vit K.
Prothrombin complex concentrate (contains factors 2,7,9,10)

Question 3

what to do if on warfarin and INR 5-8? No bleeding

Answer 3

Stop warfarin, oral vitamin K

Question 4

How do you monitor response to haemachromatosis Mx (i.e. venesection)?

Answer 4

Monitor ferritin and transferrin saturation

Question 5

What nerve is usually injured when the lateral aspect of knee/head of fibula is injured?

Answer 5

Common peroneal nerve

(the sciatic nerve divides into common peroneal nerve and tibial nerve)

The common peroneal innervates dorsiflexion and ankle eversion.

Therefore you get foot drop.

Question 6

What can be a trigger of ITP?

Answer 6

Infection

Question 7

Management of ITP?

Answer 7

Prednisolone

Question 8

At what threshold are platelet transfusions indicated?

Answer 8

If bleeding >30
If no bleeding <10

If pre-op, and surgery high bleeidng risk, transfuse to aim >100

medium risk aim 50-75

low risk aim >50

Question 9

Which blood product carries the most infection risk?

Answer 9

Platelets, as they can’t be refrigerated

Question 10

Do you have to stop the COCP prior to surgery?

Answer 10

Yes, 4 weeks before
(DVT risk)

Question 11

Which bacteria commonly implicated in neutropenic sepsis?

Answer 11

Staph Epidermidis

(due to indwelling lines commonly seen in cancer patients)

Question 12

Why do you get anaemia in CKD?

Answer 12

1) decreased EPO
2) increased hepcidin which impairs iron absorption gut

Question 13

What is the management of ITP?

Answer 13

Only needs treatment if severe bleeding or platelets less than 10

Otherwise, no treatment needed
Resolves by itself in 6 months

Question 14

What happens in tumour lysis syndrome and which cancers are high risk for it?

How can you reduce risk of it?

Answer 14

breakdown of tumour when treated, causing
HIGH K
HIGH Ph
HIGH URIC ACID
LOW Ca

Leukaemia and lymphoma

Reduce risk with IV Fluids and Allopurinol

Question 15

How do you reverse each of the anticoagulants?

Answer 15

Heparin - protamine
Warfarin - Vit K +/- PCC
Apixaban/Rivaroxaban (both 10a inhibitors) - adnexet alpha (10a)

Dabigatran (monoclonal antibody)

Edoxaban - there isn’t one licensed :/

Question 16

Which malignancies is EBV associated with?

Answer 16

Burkett’s lymphoma
Hodgkin’s lymphoma
Nasopharyngeal carcinoma

Question 17

How often should patients with sickle cell receive pneumococcal vaccine?

Answer 17

Every 5 years

Question 18

Slightly raised APTT, normal platelets, slightly low Factor 8

Bleeding

What’s diagnosis?

Answer 18

Von Willebrand Disease

(inherited)

Question 19

Which virus causes aplastic anaemia (pancytopenia) in those with haem issues (e.g sickle cell)?

Answer 19

Parvovirus B19

ie. 5th disease (slapped cheek syndrome)
- rash over face

Question 20

Which Hb rises in compensation in B thalassaemia trait?

Answer 20

Hb A2

Question 21

Which Hb is dominant in B thalassaemia major?

Answer 21

HbF

Question 22

What is HSP and what is the triad of symptoms?

Answer 22

IgA vasculitis following URTI

Abdominal pain, haematuria, joint pain (+purpuric rash/petechiae on buttocks)

Question 23

What happens to clotting factor levels in liver disease? What happens to PT and APTT?

Answer 23

Clotting factors all fall, except factor 8 (made throughout body)

APTT and PT both raised

However also at risk of thrombus as well as bleeding because natural anticoags (protein c, s, antithrombin) fall

Question 24

What are the criteria in Well’s score?

Answer 24

-Entire leg swollen
-Tender along deep venous system
-One leg 3cm more dilated than other
-Immobility in last 3 days or surgery requiring GA in last 12 weeks
-Previous DVT
-Active cancer
-Paralysis or casting of leg
-Pitting oedema on that leg only

-2 points of Other diagnosis as likely

Question 25

How to use Well's score in suspected DVT?

Answer 25

Score 1 or 0 (DVT less likely) = d-dimer. If positive, do USS. If not available in 4hrs, start treatment. 2 or more (DVT more likely) = do USS If USS going to delay more then 4hrs, start treatment and ensure USS done within 24hrs

Question 26

What to do in suspected DVT if d-dimer positive but USS negative?

Answer 26

Stop anticoagulation Offer repeat USS in 6-8 days

Question 27

Most commonly inherited thrombophilia?

Answer 27

Factor V Leiden

Question 28

What is CML and what are the symptoms?

Answer 28

Increased granulocytes at different stages of maturation Increased WCC +/- increased platelets Low Hb - anaemia Massive splenomegaly -> abode discomfort Occurs due to Philadelphia chromosome (9:22 translocation, forming BCR:ABL fusion gene which produces overly active tyrosine kinase protein -> cell proliferation)

Question 29

What is the management of CML?

Answer 29

1st line = imatinib (TKI)

Question 30

What are the causes of massive splenomegaly?

Answer 30

CML Myelofibrosis

Question 31

Management of beta thalassaemia major?

Answer 31

Regular bloods transfusions (they don't have HbA - instead increased A2 and F) But need also desferioxamine to prevent iron overload

Question 32

What are the official diagnostic criteria for multiple myeloma?

Answer 32

Need 1 major and 1 minor Orr 3 minor major: plasmacytoma identified on biopsy, plasma cells >30% in BM, elevated M proteins blood/urine minor: plasma cells 10-30% BM, slightly elevated M protein blood/urine, osteolytic lesions, low non-cancer antibody levels in blood

Question 33

What is the management of sickle cell patients long term?

Answer 33

Hydroxyurea to prevent attacks And they should have the pneumococcal vaccine every 5 years

Question 34

How should you manage antiphospholipid patients when they're pregnant?

Answer 34

Stop warfarin Start aspirin from 12 weeks (to prevent pre-eclampsia) Start LMWH once fetal heartbeat detected They are at increased risk of VTE especially during pregnancy!!

Question 35

Indications for warfarin as 1st line anticoagulant?

Answer 35

Metallic heart valve, valvular AF Antiphospholipid syndrome

Question 36

Coeliac disease + splenomegaly = WHY? What do you see on blood film as a consequence?

Answer 36

Coeliac disease causes functional hyposplenism You may see Howell Jolly bodies (RBC remnant) and target cells on blood film - basically cos spleen isn't working as well to remove abnormal blood stuff

Question 37

Effect of EBV on FBC?

Answer 37

Lymphoyctosis and neutropenia (the former can precipitate recurrent infections)

Question 38

NB// FERRITIN IS ACUTE PHASE REACTANT AND WILL BE RAISED WHEN UNWELL (so can be deceivingly normal or high in someone with IDA when they're acutely unwell!)

Question 39

What are the causes of microcytic anaemia?

Answer 39

1) Iron deficiency is most common (in females, think GI loss vs menorrhagia) 2) Thalassaemia

Question 40

When should you transfuse platelets?

Answer 40

If no bleeding, <10 if significant bleeding <30 (i.e. malaenia, haematemesis, prolonged epistaxis)